CMS Official Sidesteps Offer Of Tools To Combat Medicare Improper Pay

House Ways & Means Republicans asked CMS acting program integrity director Jonathan Morse what additional tools the agency might need to help bring down improper payment rates in Medicare — 11 percent for Medicare fee-for-service and about 10 percent for Medicare Advantage in fiscal 2016, according to the government’s payment accuracy website — but Morse did not ask for any additional authority, even though a representative from the Government Accountability Office suggested lawmakers could give CMS the authority to let Recovery Audit Contractors conduct pre-pay reviews.

“Bad actors are real and it is important that we continue to provide support for the effort to combat fraud. However, errors other than fraud require a different approach. This makes efforts to distinguish between fraud and other improper payments important. In the end we need to look for ways to reduce all types of errors and ensure that the mechanisms created to do this are working as intended,” Buchanan’s opening statement says.

Morse said that the agency looks at the improper payment rate as an estimate for the program, and he also pointed out that about 60 percent of the improper payments in fee-for-service Medicare are documentation errors — the other 40 percent is more suspect behavior.

Morse noted that the improper pay rate for Medicare has come down from 12 percent in fiscal 2015 to 11 percent in fiscal 2016, though he said the agency is working to continue bringing it down as that number, from CMS’ perspective, is too high.

Buchanan suggested more needs to be done. “We need to make sure we’ve got good, accurate information, the best we can, in terms of the trend lines and where all of this is going, because obviously 10 percent of a huge program…that’s outrageous, that’s why it caught so much of my attention. These big programs, Social Security and Medicare, it doesn’t take a big percentage to get to a gigantic number. And that’s why I think we need to put whatever resources we can to take the trend line and move it in the other direction,” Buchanan said.

Buchanan and Rep. Carlos Curbelo (R-FL) asked what the committee could do to help the improper payment rate decrease. Morse told Curbelo that Ways & Means has “done a fantastic job” of helping CMS already, and he touted an increase in funding for the Health Care Fraud and Abuse Control Program, as well as the Medicare Access and CHIP Reauthorization Act, the Comprehensive Addiction and Recovery Act, and Small Business Jobs Act.

However, Morse did not mention the Affordable Care Act, or the additional tools that legislation gave CMS with regards to tackling waste, fraud and abuse. Even when asked by Rep. Joseph Crowley (D-NY) how the ACA has affected the agency’s ability to handle improper payments, Morse responded by listing the other pieces of legislation, and said the ACA was just one piece of legislation that has been helpful.

“I recognize those additions, but I was just focusing [on the ACA] specifically because those other provisions are not under attack, so to speak, in the same way that the ACA has been…and I would hate to see these ACA provisions and the program integrity efforts initiated by the Obama Administration be reversed,” Crowley said.

When James Cosgrove, director of health care for the Government Accountability Office, was asked what the committee could do to help CMS tackle waste, fraud and abuse, he suggested more pre-payment reviews. He noted the RAC pre-payment review demonstration, and said GAO has recommended CMS seek legislative authority to allow the RACS to conduct pre-payment reviews, as he said those reviews are more effective and efficient than post-pay reviews. — Michelle M. Stein